Death of patient prompts an upgrade in diabetes care

The Nuffield Orthopaedic Centre

The Nuffield Orthopaedic Centre

First published in News Oxford Mail: Photograph of the Author by , Health reporter, also covering Kidlington. Call me on 01865 425271

A PATIENT’S death and a review of care standards prompted an improvement of diabetes care in the county, hospital bosses say.

An investigation into the death at Nuffield Orthopaedic Centre in March last year led in part to the Oxford University Hospitals NHS Trust (OUHT) assessing the care provided.

This included the death of the patient in March last year from which “a number of issues were identified with the care provided” a report said.

That came two months after a review of 2011 and 2012 figures found the trust underperformed compared to the national average.

This included issues like access to sepcialist diabetes support and how outcomes for patients, like hypoglycaemia episodes, a result of low blood sugar. Consequent “risk summits” – which bring together health experts to discuss concerns – flagged up a number of improvements to be made to diabetes care across the trust.

A report to trust directors by acting chief nurse Liz Wright said: “Following this, it was agreed that diabetes care should become a priority topic.”

Extra staff, a review of education and better standardisation of care had since been put in place.

OUHT refused to give the Oxford Mail any more details about the death, which was subject of a “serious incidents requiring investigation” (SIRI) inquiry.

A spokesman said: “The trust cannot legally discuss an individual patient or patient records.”

The worries were raised in a report to trust board directors updating them on inpatient diabetes services.

Following the death, the trust said: “An action plan was established and improvement actions taken forward within the division where the event occured.”

It added: “Key proposals coming out of the risk summits included the need for increased specialist diabetes support across all hospital sites, improved educational material, better use of information technology to identify patients with diabetes and to prompt specific intervention, and standardisation of care for patients with diabetes.”

The trust – which also runs Oxford’s John Radcliffe and Churchill hospitals – has approved £535,000 extra a year for staffing.

This will include full-time podiatry roles – diabetes can reduce blood supply to the foot – from one to four and more than doubling the number of specialist nursing roles.

An extra two consultants were hired in the year from last April to make a total of eight, and another will be taken on by January.

A trust diabetes quality group has been set up, four level of education identified and a “Think Glucose” guide adopted to standardise care.

Acting deputy medical director Ian Reckless said: “We regularly look at the quality of the services we provide, including that of the diabetes service.

“Based on our regular data reviews, we identified that our inpatient service needed improvement.”

Diabetes UK’s regional manager for the South East, Jill Steaton, said: “The fact that the trust is trying to improve inpatient services by providing better training for staff and investing in diabetes specialists is really good news.”

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